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Expected Changes in the Nursing Mother's Breasts Your breasts will change significantly during the first week after giving birth as they begin their job of making and releasing milk. As stated previously, a wide range of normal exists for when milk comes in abundantly, the amount of milk women produce, the magnitude of breast enlargement or firmness that occurs, and the ease of milk flow. Make it a point to pay attention to your breasts and the clues they can offer about the success of breastfeeding. The following guidelines will let you know what to expect and when to seek help.

A mother's milk usually starts being produced in abundance two to four days after delivery. Colostrum, the early milk produced by the breasts, is present in relatively small amounts, beginning months before delivery and continuing for the first few days after giving birth. The process of abundant milk production (known as lactogenesis) begins approximately two to four days after delivery. In the past, lactogenesis occurred while a mother was still in the hospital. At the time of a mother's discharge, her milk already had increased and the nurses assisting her could be reasonably certain whether breastfeeding was off to a satisfactory start. Today, however, most women are already home when lactogenesis occurs. They may encounter unexpected discomfort or difficulty latching their baby on correctly when their breasts are engorged.

A woman's breasts become larger, firmer, heavier, warmer, and even uncomfortable when her milk starts increasing in volume. While these changes are more dramatic in some women than in others, the large majority of mothers can readily tell whether their milk has come in abundantly. The scant clear or yellow colostrum changes in appearance to whitish milk and greatly increases in quantity. The sudden increase in milk production may be evident by spontaneous leaking from the breasts or by seeing milk in the baby's mouth.

Most often, increased milk production begins two and a half to three days after delivery. Milk tends to come in earlier among women who have given birth previously and those who delivered vaginally, compared to first-time mothers or women who had C-sections. Occasionally, however, milk starts coming in abundantly as late as five to seven days. Often the delay is due either to medical problems in the mother or to severe emotional upset. For example, I have seen lactogenesis be delayed or diminished in some women with high blood pressure, excessive blood loss at delivery, serious infections, severe pain, or extreme emotional stress.

For many women, postpartum breast engorgement is uncomfortable, and in a few it is downright miserable. For most women, it is an unmistakable occurrence, but for a small minority, it is barely perceptible. While some women who scarcely notice whether their milk has come in go on to breastfeed successfully, I consider lack of significant postpartum breast engorgement to be a red flag worthy of investigation.

WHEN TO SEEK HELP: In a tiny percentage of women-sometimes those who are very ill postpartum-milk fails to come in normally and full lactation is not possible. Such a woman may experience little, if any, breast engorgement, and her milk production may not climb sufficiently to nourish her baby. That's why I never ignore a mother's statement, "I'm not sure if my milk ever came in." If your baby seems hungry after most feedings and you do not think your milk has come in by four days postpartum, you should contact your baby's doctor and have your infant weighed to make sure she has not lost excessive weight from birth.

If you experience severe breast engorgement, with hard, painful, swollen breasts, you should also be concerned. Severe engorgement makes it difficult to get milk flowing well, and the resulting pressure can lead to decreased milk production (believe it or not!). Excessive engorgement can also cause extreme discomfort, problems getting the infant latched on, sore nipples, and poor milk intake by the baby. Contact your own and/or your baby's doctor if your breasts are severely engorged. Ask to be referred to a lactation consultant who can help you obtain and use an electric breast pump to express milk and soften your breasts.

A mother's breasts usually feel full before each feeding (suggesting milk is present) and become softer after the baby has nursed (suggesting that milk has been emptied). Earlier, I recommended that you alternate the breast on which you start feed-ings. Some counselors advise women to move a safety pin from one bra strap to the other to remind them on which side to begin. Successful nursing mothers usually admit that they need no such reminder because the fuller breast is so obvious to them. Try to learn to pay attention to such changes in your breasts as long as you breastfeed.

After your longest night interval between feedings, your breasts should feel particularly full. Often, a woman will leak milk onto her bed sheets or become so full that she awakens before her baby demands. These are additional indicators of plentiful milk production.

WHEN TO SEEK HELP: Generalized breast fullness that doesn't decrease with feeding could suggest that your baby is not extracting the milk effectively. On the other hand, soft breasts that don't feel fuller before nursings could imply that little milk is available at a feeding. Patchy, or localized, breast fullness also can suggest a problem. Obviously, these observations are rather subjective and are less precise in predicting a problem than many of the other breastfeeding criteria described in this chapter.

A mother's nipples might be mildly tender for the first several days of nursing. Nipple tenderness usually is present only at the beginning of feedings and subsides as the feeding progresses. Discomfort should not interfere with feedings and usually improves once milk starts to come in abundantly. By the end of the first week, breastfeeding is usually comfortable.

WHEN TO SEEK HELP: Severe nipple pain that makes you dread nursing your baby, pain that lasts throughout a feeding, or pain persisting beyond one week all are considered abnormal. Most likely, your baby is not breastfeeding correctly. If your infant isn't latched on properly or sucking correctly, not only will your nipples hurt, but your baby may not obtain sufficient milk. Thus, if you have severe sore nipples, you should obtain help with your nursing technique and have your baby weighed. Severe cases might require using a hospital-grade rental electric breast pump until your nipples are healed.

After two or three weeks, nursing mothers usually notice the sensations associated with the milk ejection, or milk let-down, reflex. One of the hormones released from your pituitary gland during nursing is known as oxytocin. Oxytocin is important to the success of breastfeeding because it causes tiny muscle cells around the milk-producing glands to squeeze milk out of the glands and into the milk ducts. This propelling of milk from the milk ducts is called the milk ejection reflex or the let-down reflex. Oxytocin release helps milk produced in the glands become available to the baby. Once a woman's milk supply is well established, the milk ejection reflex causes noticeable breast sensations, such as tingling, tightening, stinging, burning, or a pins-and-needles feeling. It can take a couple of weeks to perceive these breast sensations. When your milk ejection reflex is triggered, your baby may start to gulp milk, and milk may drip or spray from the other breast. Just hearing your baby cry or holding your infant can cause your milk to "let-down," even before your baby latches on.

WHEN TO SEEK HELP: Although many women breastfeed just fine without noticing signs of the milk ejection reflex, failure to perceive the typical let-down sensations by three weeks postpartum could mean that your milk supply is low. Generally, the more abundant the milk supply, the more dramatic the signs of let-down, but this is not a hard-and-fast rule. If you are in doubt about your milk supply, have your baby weighed.

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